CHNAES-00544; No of Pages 8 Acta Ecologica Sinica xxx (2018) xxx–xxx
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The cutaneous leishmaniasis vulnerability index (CLVI) Ahmed Karmaoui Department of Biology, Southern Center for Culture & Sciences (SCCS), Zagora, Morocco
a r t i c l e
i n f o
Article history: Received 15 August 2017 Received in revised form 29 December 2017 Accepted 2 January 2018 Available online xxxx Keywords: Leishmaniasis vulnerability Multidisciplinary Risk factors Indicators Socio-economic
a b s t r a c t South east of Morocco is one of the biggest cutaneous leishmaniasis disease foci. Despite its non-lethality, this disease causes several socioeconomic and psychological impacts. This disease has lots of risk factors. Some of these are related to the environmental change, and others are linked to the demographic and socio-economical system. The interactions between these risk factors create the need for a multidisciplinary approach to estimate the vulnerability risk to the cutaneous leishmaniasis. In this context, a new index was proposed and six provinces were selected, which are Zagora, Ouarzazate, Tinghir, Errachidia, Figuig, and Tata. The findings depict that in term of anthropogenic vulnerability, Tinghir is the most vulnerable to leishmaniasis followed by Errachidia and Ouarzazate. Geographically, Errachidia has the very high vulnerability score and Figuig have the high vulnerability. The results show also an important risk to leishmaniasis in all provinces regarding the socio-economical component, except for Tata. Regarding services category, Zagora is the most vulnerable. However, for the hygiene, Figuig, Ouarzazate, and Errachidia present the high scores of vulnerability, then the rest provinces. The total score of cutaneous leishmaniasis vulnerability of the selected provinces indicates that Tinghir is the most vulnerable regarding this disease followed respectively by Errachidia, Ouarzazate, Zagora, Figuig, and Tata. © 2018 Published by Elsevier B.V. on behalf of Ecological Society of China.
1. Introduction The vector-borne diseases are all diseases transmitted by vectors like insects and other vectors. According to the World Health Organization [1], more than half of the world's population is at risk of these diseases. Among these diseases, we can cite by way of example malaria, yellow fever, schistosomiasis, leishmaniasis … etc. The incidence of these diseases is frequent mainly in the poorest countries. In Morocco, the leishmaniasis constitutes the first parasitic disease followed by the Malaria and Bilharziasis. In fact, the leishmaniasis represents 84% of the recorded cases at the national scale [2].Talking about leishmaniasis in Morocco, there are three species of Leishmania, L. major (ZCL), L. tropica (CL) and L. infantum (ZVL, CL). In pre-Sahara, ZCL has been identified for the first time in 1914 [3], and the main vector, Phlebotomus papatasi in 1916 [4]. In this paper, special attention was given to the first type of leishmaniasis, the L. major (ZCL). The causative agent or vector is the Phlebotomus papatasi and the reservoirs are Meriones shawi, and Psammomys obesus [5]. The leishmaniasis is confined to Moroccan Sahara and pre-Saharan region because this region creates favorable conditions for the sand fly vectors. These poorest provinces are the most affected by this disease. The Sahara and pre-Saharan region is characterized mainly by an arid climate and the vegetation is concentrated mainly in oases system [6–9].
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Obviously, there are several variables that promote the expansion of cutaneous leishmaniasis, hence the need for an integrated approach. This can take into account the most important variables that are helpful in predicting the expansion. In this paper, a multidisciplinary approach to measure the vulnerability to cutaneous leishmaniasis is needed. In this context, we propose a new index that uses 22 variables or indicators. The data of used indicators of the seven components were prepared and compiled for the six selected provinces. In order to estimate the cutaneous leishmaniasis vulnerability for these provinces, the missing data for the 22 indicators was 0%. All the used data were provided by official sources as provided in material and methods section. The used indicators show all possible aspects of the biophysical and social system related to the cutaneous leishmaniasis disease. This paper gives a new tool to understand the expansion of this disease toward the associated risk factors. Dry land including, the oases of Morocco is the most threatened by this phenomenon. The desert biome is the suitable habitat of sand fly, the vector of leishmaniasis. Water and vegetation are concentrated in biome called oasis with its arid conditions favors the existence of both the vector and the reservoirs. We used different spatiotemporal information in the Moroccan dry land, following the availability of official data. In this area, the environment and aquatic ecosystems are at risk and vulnerable to climate change and anthropogenic factors [10]. The index integrates several aspects related to the leishmaniasis disease in this region. The purposes of this paper were to: - give an overview of the leishmaniasis situation in Morocco and in pre-Sahara region by the illustration of the leishmaniasis
https://doi.org/10.1016/j.chnaes.2018.01.001 1872-2032/© 2018 Published by Elsevier B.V. on behalf of Ecological Society of China.
Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001
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distribution; - to validate the applicability of the proposed index regarding the cutaneous leishmaniasis transmission; - to compare the vulnerability of cutaneous leishmaniasis for the six selected provinces.
2. Material and methods 2.1. Study area At national scale ten provinces know the distribution of Zoonotic cutaneous leishmaniasis (ZCL), Boulemane, Errachidia, Figuig, Jrada, Midelt, Ouarzazate, Taourirte, Tata, Tinghir, and Zagora. The six most important provinces are Zagora, Ouarzazate, Tinghir, Errachidia, Figuig, and Tata were selected (representativeness). These later provinces recorded 70.4% of cases of leishmaniasis in 2009 and 87% in 2014 compared to the total cases at national scale [2]. These provinces are situated in the south east of Morocco (Fig. 1), where the climate is a semi-arid to arid. These provinces are the endemic focus of cutaneous leishmaniasis [11]. The aridity, the frequent drought, and the social vulnerability make the region vulnerable to the parasitic diseases. Both at Moroccan and pre-Saharan scales, the leishmaniasis constitute the first parasitic disease followed by the Malaria and Bilharziasis (Fig. 2a and b). The main characteristics of the study area regarding the leishmaniasis transmission (cutaneous and visceral) are illustrated in Fig. 2 c and d. The important number of leishmaniasis cases affects individuals with the age above 9 years followed by the age between 10 and 19 (Fig. 2c). The above 19 age group is particularly at risk for leishmaniasis,
which influences school attendance. This has repercussions on the human development and, subsequently, economic growth because the good health plays an important role in economic productivity. An increase of threat (the trends) can be seen in the period 2004–2010 and a rapid decrease from 2010 to 2014 (Fig. 2d) because of the government intervention after the epidemic year, 2010. This intervention was in form of rodent control and hygiene or waste management and through the free treatment and care of leishmaniasis cases. The oasean ecosystems are located in the southern provinces of Morocco. These provinces constitute the Pre-Sahara region. The oasis is a wet zone in desert and plays a crucial role in supporting the population by providing the ecosystem services (water, food, and energy) that ensure the well-being. In the oasis, the main economic activity is the agriculture. The climate is arid and the rainfall is very irregular in time and space [8]. The population in the region is mostly rural and socially fragile. The Oasis system is known by a complex hydraulic system and an intense agricultural activity in the palm groves. The environmental, especially the aquatic ecosystems change are the biggest global concerns that can impact the human health and then the well-being. This later is far from being achieved. This is more alarming in Africa where water vulnerability is a real issue. Among the most important, we can cite the leishmaniasis expansion. The sand fly is the vector that supports this disease. This insect, with a nocturnal and twilight activity, has a holometabolic cycle including the egg, four larval stages, a nymph and the imago [12]. As mentioned below, the presence and the expansion of this vector related to the presence of a reservoir. The Leishmaniasis major (LM) reservoir is Psammomys obesus and Merioness hawi [13] that exist in polluted sites. As reported by several authors [14–16,17], the climate change impacts the repartition of the LM vectors and reservoirs. For the
Fig. 1. Localization of the study area, including the six selected provinces, south of Morocco.
Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001
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Fig. 2. Profile of leishmaniasis transmission at Moroccan and pre-Saharan scales; a, comparison of the parasitic diseases at Moroccan scale in 2014; b, comparison between parasitic diseases in the six pre-Saharan sites; c, ZCL cases by ages in 2014 at national scale; and d, comparison between visceral and cutaneous leishmaniasis at national scale. Data source: [2].
repartition of ZCL, Kahime et al. [11] reported that foci are especially associated with the palm groves (pre-Saharan desert oasis), as well as the peri-urban zones with low socio-economical conditions. Topographically, the P. papatasi is common at 400–800 m a.s.l [18] and is suitable to arid conditions. The limited control of the leishmaniasis in these regions is due to poverty and the weakness of health systems [19]. 2.2. Methodology The data used in this paper were provided by different sources (the archives of the Moroccan health Ministry, the High Commission for Planning, and academic scientific articles). In the Pre-Sahara, the data on ZCL cases are difficult to obtain. Additionally, the complexity of interaction between different variables associated with the transmission of ZCL increase this difficulty. The gathered data included several aspects related to the leishmaniasis (ZCL) transmission, such as anthropogenic, geographical, socio-economical, services, health, climatic and hygiene characteristics. We gathered and compiled all possible factors involved in an oasis, where the disease is known. A set of scientific papers were analyzed. The assembled information gives the state and the trend of the disease in relation to several impact factors. Six provinces of the south eastern Morocco were proposed to validate this new index. This is a numerical model that uses 22 variables, categorized as follow: Anthropogenic (population, density, and urban population);Geographical component (land area and altitude); Socioeconomical (illiteracy, unemployment, urban and rural poverty); Services category (television, radio, wood using, and drinkable water); Health component (leishmaniasis cases, health personal, urban and
rural consultations). However, Flood and Rainfall were used for a climatic category, and rural houses, WC, sanitation for hygiene component (Table 1). All these variables interact in a complex way. It is the interactions between socioeconomic and biophysical factors that will determine the distribution of vector-borne diseases (leishmaniasis) (Fig. 3). Both components are influenced by climatic conditions induced by climate change. Any change in socioeconomic and biophysical components can impact climate change. All the necessary data for each individual variable were gathered, compiled and integrated into the leishmaniasis index (Table 1). The data were normalized in a manner to be represented in one scale ranging between 0 and 1. Where 1 indicates a high vulnerability and 0 indicates very small vulnerability- resilience to cutaneous leishmaniasis. The used indicators categorized following the main elements of vulnerability, the susceptibility, exposure, and resilience as mentioned in the Eq. (1) [20]. Where, the exposure refers to the predisposition of a population to be impacted by a vector borne disease, the susceptibility can be defined here, as the socio-physical characteristics facing the disease, and resilience that is the capability to adapt and resist to the disease risk. CLVI ¼
Exposure Susceptibility Reselience
ð1Þ
The following are the equations used to estimate the vulnerability of anthropogenic (Eq. (2)), geographic (Eq. (3)), socio-economical (Eq. (4)), services (Eq. (5)), health (Eq. (6)), climate (Eq. (7)), and hygiene component (Eq. (8)) to the cutaneous leishmaniasis. For the abbreviation see Table 1.
Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001
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Table 1 Variables favoring the expansion of LM (leishmaniasis cases) categorized by component, anthropogenic component; geographic, socio-economical, services, health, climate, and hygiene component. Categories
N
Indicators
Description
Unit
Anthropogenic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Population (P) Density (D) Urban population (U) Land area (L) Elevation (E) Illiteracy (A) Unemployment (Un) Urban poverty (Up) Rural poverty (Rp) Television (T) Radio (R) The use of wood (W) Drinkable water (Dw) Leishmania cases (Lc) Health personal (Hp) Urban consultations (Uc) Rural consultations (Rc) Floods (F) Rainfall (Rf) Rural houses (RH) WC (Wc) Sanitation (S)
Population (2014) Density (2014) Urban population (2014) Land area (2014) Elevation (m a.s.l.) Illiteracy rate (2014) Unemployment (2014) Poverty severity index (urban) (2014) Poverty severity index (rural) (2014) Television (2014) Radio (2014) Cooking by wood (2014) Drinkable water (2014) Leishmania cases (2014) Total number of doctors (2014) Mean number of consultations per habitant in urban area, (2014) Mean number of consultations per habitant in rural area, (2014) Years between floods Average annual rainfall variability Rural houses (rural construction) (2014) WC (2014) Public Sewerage Network (2014)
nb nb/km2 nb km2 m % % Index Index % % % % nb nb Nb percap Nb percap Years mm % % %
Geographical Socio-economical
Services
Health
Climate Hygiene
• Anthropogenic component: CLVI a ¼ ½P; D; U
• Services component: ð2Þ
• Geographical component: CLVI g ¼ ½L; E
½W ½T; R; Dw
ð5Þ
• Health component: ð3Þ
• Socio-economical component:
CLVI se ¼ ½A; Un; Up; Rp
CLVI s ¼
CLVI h ¼
½Lc ½Hp; Uc; Rc
ð6Þ
• Climate component: ð4Þ
CLVI c ¼
½Rf ½ F
ð7Þ
Fig. 3. Interactions between socioeconomic and biophysical factors in context of climate change.
Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001
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• Hygiene component: CLVI hg ¼
½RH ½Wc; S
ð8Þ
For each individual indicator, five vulnerability classes were identified (Table 2), where 1 indicates a very high vulnerability, high vulnerability, medium vulnerability, low vulnerability and 0 indicates very low vulnerability. The sum of the six used components gives the total Cutaneous Leishmaniasis Vulnerability Index (CLVI), see formula Eq. (9). CLVI total ¼
X
CLVIa; CLVIg; CLVIse; CLVIs; CLVIh; CLVIc; CLVIhg
ð9Þ
The used statistical method to study the relationship between the values of two variables or two components is Pearson correlation (significant at the 0.05) as stated in the following formula (Eq. (10)) for the six selected sites. r¼
1 X xi −X yi −Y n−1 sx sy
ð10Þ
Where, X and Y are the correlated variables, X and Y, the mains, and Sx and Sy, the standard deviations. To carry out the statistical analysis, we used the Arab processor in social statistics software (APSS 1.0). 3. Results & discussion 3.1. Applicability of the cutaneous leishmaniasis vulnerability index The proposed tool helps to identify and prioritize the most vulnerable areas to cutaneous leishmaniasis (ZCL). The transmission of leishmaniasis is linked with several risk variables. In fact, there are factors purely anthropogenic, other have geographical characters. In addition, socioeconomic and services & resources factors also play a very important role in the disease transmission. For example, climatic factors accelerated the incidence of disease by providing vegetation conditions and water availability that support both the vector and the reservoir of the agent that causes the disease. The main indicators related to the leishmaniasis transmission are summarized in Table 3. In term of anthropogenic vulnerability (Table 3 and Fig. 4a), Tinghir is the most vulnerable to leishmaniasis followed by Errachidia and Ouarzazate due to the high number of the population both total and urban. This justifies the high rate of urbanization. WHO [21] agree with this considering that urbanization is one of the major risk factors of leishmaniasis. The population density is another aspect of anthropogenic factors that have an impact on leishmaniasis infection. In fact, after Ramos et al. [22], an abundance of sand flies is localized in zones with high population density. Concerning the geographical vulnerability (Fig. 4b), Errachidia has the very high vulnerability and Figuig and Ouarzazate have high vulnerability scores because of the high surface area and high rural population. However, Zagora, and Tata have the low score of vulnerability. For the socio-economical vulnerability (Fig. 4c), Tinghir and Zagora have the very high vulnerability, Ouarzazate, Errachidia followed by Figuig have medium vulnerability, and Tata the less vulnerable. In this
Table 2 Cutaneous leishmaniasis vulnerability designations. Index value
Designations
b0.2 0.2 to 0.4 0.4 to 0.6 0.6 to 0.8 0.8 to1
Very low vulnerability to cutaneous leishmaniasis Low vulnerability to cutaneous leishmaniasis Medium vulnerability to cutaneous leishmaniasis High vulnerability to cutaneous leishmaniasis Very high vulnerability to cutaneous leishmaniasis
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context, in several countries, the cutaneous leishmaniasis (CL) is considered as a public health and as a social problem [23]. After Ready [24], the socio-economical changes influence the human contacts rate with the leishmaniasis cycle. This is due, firstly, to the low poverty severity index score in Tata and the high score in the other selected sites calculated by GCPH [27]. Secondly, this is due to the high rate of unemployment as a challenge for life conditions development and also due to a high rate of illiteracy. This latter is one of the most sources of information and health-environmental education. Regarding the services category, Zagora is the most vulnerable than the other selected sites (Fig. 4d), this is due to the relative low rate of access to services such as drinking water, television, radio, and wood energy. In fact, the television and radio are among the main sources of information on all aspects of health problems. In addition, the Media can support the local population with the utile and helpful information to avoid behaviors accelerating the leishmaniasis transmission (house and body hygiene, animal contact, polluted water as sources of vectors…). The rural houses use woods as a main source of energy in cooking, which rising the CO2 and odors released which bring the sand flies as reported by Yared et al. [25]. For the access to clean water is an evidence that clean water in the houses avoid the withdrawing water from sources such as wells, and then store it in a reservoirs that can support vectors of leishmaniasis (larva). In addition, the quality of water can affect water-related diseases what impacting the health of vulnerable areas. In terms of climatic indicators (Fig. 4e), Ouarzazate and Errachidia (the very high vulnerability), and Tinghir have the high score of vulnerability. The hygiene category (Fig. 4g) uses rural houses (housing conditions), WC and sanitation variables. Following this component, Figuig scores (1.0), which classifies it as very high vulnerable, Ouarzazate and Errachidia have the high vulnerability. However, Tata and Zagora have moderate vulnerability. Poor water quality and lack of sanitation lead to transmission of water-related diseases such as leishmaniasis. This exposes local populations to these health risks. Wastewater produced and standing water is a source of transmission. Insects adult and larvae live in stagnant water or on the water in open reservoirs carry diseases such as leishmaniasis. The health category gathers the indicators like cases of leishmaniasis, the personal health care (disease treatment and health information transfer) and the medical consultation rate (Doctor-patient interaction) of the local population (urban and rural). In term of health vulnerability, Tinghir is the most vulnerable. As mentioned above, the leishmaniasis disease is linked to poverty, water and also to poor public services such as health, and electricity and sanitation. In order to combat these diseases, health public services must be improved and placed at the top of the centers' priorities. The climate is another aspect of risk factors. As reported in several studies [11,26], the climate can affect the repartition of the leishmaniasis. After Ready [24], it can impact the reservoir or the vector physiology or indirectly through the rainfall or temperature supporting the condition of vector abundance and agent transmission. The used indicators are the rainfall and the floods because the high impacts of the water availability that support the vegetation cover. This is the base of the reservoir and vector abundance. As mentioned in the study area section, the precipitation in the pre-Sahara is in majority floods as in other arid areas. Overall, the total score of cutaneous leishmaniasis vulnerability of the selected provinces (Fig. 4h) indicates that Tinghir is the most vulnerable regarding this disease followed respectively by Zagora, Ouarzazate, Errachidia, Figuig, and Zagora. In the studied areas, agriculture and livestock are the main economic activities. Around these activities is developed the trade of agricultural productions, livestock, and cereals. The region is geographically (Fig. 1) and socio-economically on the periphery on ecologically fragile lands, which increases its exposure and vulnerability to climatic events. Socially, rural and urban communities are rarely homogeneous or egalitarian. All these factors contribute to widespread poverty in rural areas and the dependence of the poorest on ecosystems. Following the
Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001
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Table 3 Indicators scores (normalized values) of the cutaneous leishmaniasis (ZCL) following the seven proposed categories for the six selected cutaneous leishmaniasis foci provinces (Morocco). Categories
N
Indicators
Ouarzazate
Zagora
Tata
Figuig
Errachidia
Tinghir
Anthropogenic
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22
Population Density Urban population Land area Elevation Illiteracy Unemployment Urban poverty Rural poverty Television Radio Wood Drinkable water Leishmania cases Health personal Urban consultations Rural consultations Floods Rainfall Rural houses WC Sanitation
0.71 0.61 0.81 0.35 0.99 0.73 0.50 1.00 1.00 1.00 1.00 0.19 1.00 1.00 0.83 0.55 0.31 0.67 1.00 0.70 0.99 0.81
0.73 0.54 0.37 0.41 0.83 0.80 0.66 1.00 1.00 0.95 0.81 1.00 0.90 0.37 0.35 0.55 0.23 0.67 0.50 1.00 0.96 0.34
0.28 0.29 0.27 0.46 0.45 0.79 1.00 0.29 0.53 0.94 0.69 0.61 0.98 0.05 0.35 1.00 0.15 1.00 0.50 0.92 0.95 0.36
0.33 0.10 0.48 1.00 0.47 1.00 0.79 0.52 0.77 0.68 0.51 0.39 0.63 0.13 0.26 0.18 1.00 1.00 0.45 0.49 0.66 0.99
1.00 0.36 1.00 0.83 0.84 0.57 0.64 1.00 1.00 1.00 0.91 0.55 0.92 0.05 1.00 0.82 0.15 0.67 1.00 0.49 1.00 1.00
0.77 1.00 0.54 0.23 1.00 0.80 0.75 1.00 1.00 0.91 0.68 0.55 0.87 1.31 0.09 0.82 0.15 0.89 0.85 0.74 0.93 0.30
Geographical Socio-economical
Services
Health
Climate Hygiene
Fig. 4. Cutaneous leishmaniasis vulnerability of the selected case studies classified by the seven categories. Comparison of the cutaneous leishmaniasis vulnerability for the six selected cutaneous leishmaniasis foci provinces; a, anthropogenic component; b, geographic; c, socio-economical; d, services; e, health; f, climate; g, hygiene; and h, total scores.
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Table 4 Pearson correlations (r) between the six used components (anthropogenic, geographical, socio-economical, services, health, climate, and hygiene). Anthropogenic
Anthropogenic
Geographical Socio-econo. Services Health Climate Hygiene
0.189 0.604 −0.092 0.551 0.823 −0.308
Geographical −0.027 −0.049 −0.433 0.482 0.537
Socio-eco. 0.278 0.677 0.223 −0.38
multiple interactions between these factors, a multidisciplinary approach is needed. In this context, the proposed approach allows estimating the vulnerability risk to the leishmaniasis. In order to validate this approach six provinces were selected, which are Zagora, Ouarzazate, Tinghir, Errachidia, Figuig, and Tata.
3.2. Interaction between leishmaniasis vulnerability components The table (Table 4) shows a strong to very strong positive correlations between the components, socio-economical and anthropogenic (r = 0.604), the socio-economical and health (r = 0.677), and the anthropogenic and climate (r = 0.823). The table depicts also a strong to very strong negative correlations between Hygiene and services components (r = − 0.606). An average positive correlation was found between Anthropogenic-Health (r = 0.551), Geographical- Climate (r = 0.482) and Geographical-Hygiene (r = 0.537). However, an average negative correlation was recorded between Health and Hygiene (r = −0.571), and Health-Geographical (r = −0.433). The rest relationships are positive or negative low. This can be helpful for the determination of good indicators, to avoid indicators with low correlations. Look for other indicators that are part of these components that can be strongly correlated in order to give components and indicators that dependent and can give significant and solid CLVI. For example, Services component have just one correlation with hygiene, and health have 4 correlations (with hygiene, anthropogenic, geographical, and socio-economical components). This allows us to say that the health component is good and correct selected component and hygiene needs to be improved by selecting indicators that impact the total score of the CLVI. Talking about the hygiene variables (Rural houses, WC, and Sanitation indicators), the correlation between variables (Rural houses and WC indicators) show an average negative correlation (r = − 0.425). While, the correlation between Rural houses and Sanitation indicators is very strong (r = 0.879). However, the correlation between WC and Sanitation depicts a negative low relation. From this intra-composite correlation, the WC indicator can be eliminated without affecting the index. In summary, the Oasean system is the main biological system in this area and the palm trees are the crucial element and provide the essential atmospheric and soil moisture for several forms of life. The agricultural activity and the water availability in these oasean provinces are seriously affecting the biodiversity, climate, and the health. A spatiotemporal baseline of information on leishmaniasis transmission was obtained. The paper provides and documents the main factors impacting the transmission of this disease. These factors called also vulnerability indicators were gathered and compiled in different vulnerability categories (Table 3 and Fig. 4). All these categories are associated with the cutaneous leishmaniasis transmission in the Moroccan pre-Sahara. As other parasitic diseases, the leishmaniasis transmission is accelerated by lack of hygiene and sanitation plus the low socioeconomical development and the environmental change. The paper focuses on sites that have not been well studied such as Figuig, Tinghir, and Zagora. The paper uses socio-economic, anthropogenic, services, climatic factors in a single tool. Gathering the scores of all types of categories used in this paper, a comparison between the selected provinces.
Services −0.113 −0.122 −0.606
Health −0.012 −0.571
Climate 0.028
Hygiene
The results show an important risk to leishmaniasis in Tinghir after that, Errachidia, Ouarzazate, Zagora, Figuig followed by Tata. The social vulnerability can be explained by the high rate of illiteracy and by unemployment (Table 3). In parallel to these high rates, the graph (Fig. 4c & e) shows a weak health infrastructure in the provinces with high social vulnerability. Populations with high incidence rates are populations with low infrastructure and personnel (low medical consultation rates and fewer health centers and fewer doctors). After the data in Fig. 4h, Tinghir, Errachidia and Ouarzazate present the highest risk of Leishmaniasis in the Pre-Saharan region. This vulnerability is associated with a low socioeconomic status, owning animals near the house. The cutaneous leishmaniasis has a social impact through the scarring of lesions. The factors that influence cutaneous leishmaniasis transmission include socioeconomic and environmental factors. On the one hand, access to vital services like water and sanitation allow access to education and improve living conditions; in addition human and infrastructure development reduces marginalized areas and is susceptible to parasitic diseases. Water supply (clean water) and sanitation can improve economic development and contribute to the fight against poverty. Moreover, the predominantly economic inequality of this isolated area has accelerated social vulnerability. According to official data [2], 8707 people were affected by cutaneous leishmaniasis in 2010. This can be promoted by to lack of sanitation and neglect of the hygiene of a population that is socio-economically vulnerable. Poor management of sanitation water creates favorable conditions for the transmission of parasitic disease. At this level, we are not sure that all used variables can would be responsible for the increase in the number of cases of leishmaniasis (ZCL) or if they would be consequences. Maybe to any parasitic disease for example. What is certain is that Leishmaniases are highly dependent on vectors and parasite reservoirs. As there is no man-to-man transmission, social and anthropogenic or housing conditions must favor either the vector or the reservoir. Perhaps as such variables could favoring one of the three actors of leishmaniasis (parasite - vector - reservoir). Climate change would increase the vector population and flow of people could make the vector dispersion in poor regions. Acknowledgments I would like to thank Prof. Vanete Thomaz Soccol for his helpful comments. I would like to thank also the anonymous reviewers for the valuable comments. References [1] WHO, The World Health Report 2004 – Changing History, World Health Organization, Geneva, 2004. [2] Moroccan Ministry of Health, (Direction de la Planificationet des RessourcesFinancière, Division de la Planification et des Etudes, Service des Etudes et de l'Information Sanitaire), Santé En Chiffre, Moroccan Ministry of Health, Rabat, 2015. [3] S. Boussaa, Epidémiologie des leishmanioses dans la région de Marrakech, Maroc: effet de l'urbanisation sur la répartition spatio-temporelle des Phlébotomes et caractérisation moléculaire de leurs populations(On line, PhD diss.) Université Louis Pasteur, Strasbourg, 2008http://www.theses.fr/2008STR13037, Accessed date: 5 February 2017. [4] S. Guernaoui, K. Ramaoui, N. Rahola, C. Barnabe, D. Sereno, A. Boumezzough, Malformations of the genitalia in male Phlebotomus papatasi (Scopoli) (Diptera:
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Please cite this article as: A. Karmaoui, The cutaneous leishmaniasis vulnerability index (CLVI), Acta Ecologica Sinica (2018), https://doi.org/ 10.1016/j.chnaes.2018.01.001